SaveYourself.ca helps you solve pain problems

published 9/13/07, updated 11/16/09

Your Back Is Not “Out” and Your Leg Length is Fine

The story of the obsession with crookedness in the physical therapies

by Paul Ingraham, Registered Massage Therapist (Vancouver)

Nearly everyone who has ever been to any kind of physical therapist has been told that they are deformed and fragile. In so many words. Physical therapists simply love to blame your problems on:

… and a long list of more “technical” sounding problems such as tibial torsions, steep Q-angles, or a dysfunctional scapulohumoral rhythm. Some such concerns are valid. For instance, I have a minor deformity in my right foot that has certainly caused me some muscle fatigue and pain in that extremity. In spite of this, I am a critic of these kinds of theories.

In my opinion, most biomechanical problems are much less important than is generally supposed. Not only are structural explanations for pain generally unsupported by any scientific evidence, the last 25 years of research results mostly contradicts them. Worse still, therapists can rarely agree on such diagnoses, and, even if they could agree, most of them are difficult or impossible to do anything about. Worst of all, patients are often indoctrinated with the disconcerting idea that the slightest crookedness, even a single minor “deformity,” can be nearly crippling.

I believe the evidence strongly shows that, to understand injuries and pain problems and to recover from them more effectively, both patients and professionals need to stop trying to understand the body as a mechanical thing, and start thinking in terms of neurology and biochemistry.

Biomechanical bogeymen

“Structuralism” is the excessive preoccupation in the physical therapies with biomechanical factors in pain problems — what I call the biomechanical bogeymen. In its most optimistic form, structuralism tends to fixate on just one or two biomechanical factors as the wellspring of all pain.

In the Appendix of this article, I write about a therapist who holds the stability of cuboid bone — a small foot bone — to be the key to all pain relief.

I once encountered a therapist who sincerely believed that he had identified the source of “all pain”: a consistent pattern of postural dysfunction that, in his opinion, was caused by “coriolis force” (the spin of the earth), and that (and he said this in all apparent sincerity) “the pattern should be the opposite Down Under.”1 A classic structuralist!

But structuralism isn’t just for health professionals with obviously silly ideas. Many orthopaedic surgeons and sports medicine specialists are also gung-ho structuralists. Most chiropractors are structuralists, almost by definition. The great majority of physiotherapists and massage therapists are inclined to structuralism.

These professionals are not united, of course. The doctors, for instance, justifiably roll their eyes at chiropractic structuralism — but in place of the phantom of chiropractic “intervertebral subluxations,” doctors ironically put forward their own more scientific-sounding biomechanical factors, many of which are ultimately just as silly. Doctorly structuralism is less anti-scientific than much of chiropractic thinking … but unfortunately that doesn’t make it correct.

“Structuralism” is an excessive preoccupation with biomechanical bogeymen.

In this article, I will show that they are all barking up the wrong tree. You won’t have to take my word for it: I will spell it out with references to credible scientific research which you can check for yourself.

Dire warnings

Yesterday a patient gravely informed me that a chiropractor had predicted his back pain by identifying a minor leg length difference ten years earlier.

Back pain is one of the most common afflictions in the modern world. An impressive 90% of all people will have an episode of acute back pain at some point in their lives … whether they have a “short leg” or not. Predicting such episodes is about as insightful as predicting death and taxes.

“The warning” is a common expression of structuralism. It is often a part of the sales pitch for a structural diagnosis. It simultaneously offers the client a pleasingly simplistic explanation for their pain, and yet it also manages to frighten patients into paying for therapy for the wrong reasons. The prevalence of structuralism in such scare tactics is why I originally coined the term “biomechanical bogeymen.” Therapists use structuralism to scare patients … unconsciously and always with good intentions, I’m sure!

A basic error in logic

Many times I’ve listened to patients, almost literally brainwashed by structuralists,2 seriously saying that their severe pain is the consequence of an “alignment” problem so subtle that you’d be hard pressed to diagnose it with a microscope. If such trivial defects could really wreak that kind of havoc — if people were as generally vulnerable as structuralists would have us believe — then nobody over the age of thirty would be able to walk.

People who have terrible pain problems often have excellent posture, good ergonomics — bodies that are basically in superb condition. Meanwhile, people with perfectly obvious biomechanical problems — everything from significant scoliosis to obesity — are doing just fine, thank you very much.

This discrepancy is so glaring, so clinically in-your-face, that I find it amazing that so many professionals are so keen on structuralism.

If such trivial defects could really wreak that kind of havoc, then nobody over the age of thirty would be able to walk.

The basic problem with structuralism is that biomechanical factors correlate poorly with pain problems. Really poorly. But structuralism is deeply embedded in our cultural consciousness, and we cling to it. It makes sense to us, and we’re just not going to give it up easily!

Expert backup

Don’t take my word for it. There is an extraordinary amount of evidence and expert opinion to support my opinion.

Patient complaints that originate in the musculoskeletal system usually have multiple causes responsible for the total picture.

Drs. Travell and Simons

Structuralism has been debunked by many medical researchers and experts. For instance, San Francisco orthopaedic surgeon Dr. Scott Dye has written eloquently about how ill-advised structuralism is when it comes to knee pain.3

Back pain experts Drs. Richard Deyo4 and Nickolai Bogduk5 have virtually devoted their careers to teaching doctors not to overestimate to importance of biomechanical factors in back pain. Bogduk writes brilliantly and concisely that “‘Degenerative disc disease’ conveys to patients that they are disintegrating, which they are not. Moreover, disc degeneration, spondylosis and spinal ostoearthrosis correlate poorly with pain and may be totally asymptomatic.”

And Dr. John Sarno’s career has also been about debunking structuralism in back pain.6 In 1984, he first wrote:

There is probably no other medical condition which is treated in so many different ways and by such a variety of practitioners as back pain. Though the conclusion may be uncomfortable, the medical community must bear the responsibility for this, for is has been distressingly narrow in its approach to the problem. It has been trapped by a diagnostic bias of ancient vintage and, most uncharacteristically, has uncritically accepted an unproven concept, that structural abnormalities are the cause of back pain.

Mind Over Back Pain, by John Sarno, p112

If not structure, then what? Soft tissue pain experts like the late Dr. Janet Travell, Dr. David Simons, Dr. Siegfried Mense, and Dr. Chan Gunn have made major scientific contributions toward understanding the more subtle and complex alternatives to structuralism. Each of these physicians has written extensively on the subject. Simons in particular writes both passionately and clearly about the neglect of this important subject:

Muscle is an orphan organ. No medical speciality claims it. As a consequence, no medical specialty is concerned with promoting funded research into the muscular causes of pain, and medical students and physical therapists rarely receive adequate primary training in how to recognize and treat myofascial trigger points.

Simons

And of course there is a lot of science that debunks structuralism …

Direct scientific evidence that structuralism is out to lunch

Many key scientific studies over the years have undermined major structuralist assumptions

My favourite has always been the leg length study published way back in 1984, in the venerable British medical journal Lancet. That paper that showed that leg length differences were unrelated to back pain, period — no correlation even, let along a causal relationship.7

Last year, Grob et al published findings in the European spine journal that abnormal neck curvatures do not have any connection with neck pain,8 and Devan et al published in Journal of Athletic Training that they couldn’t find any connection between knee injuries like iliotibial band syndrome and patellofemoral pain syndrome and any of the mechanical “usual suspects” that are blamed for those conditions.9

The British medical journal Lancet published proof in 1984 that leg length differences do not correlate with back pain.

A bizarre and amazing scientific study published in New England Journal of Medicine in 2002 showed that a placebo for knee osteoarthritis is just as good as real surgery.10 A more “mechanical” problem than rough knee cartilage can hardly be imagined, yet 150 people who received a sham surgery recovered just as well as people who actually got their cartilage polished. It’s hard to imagine a more crushing blow to structuralism!

Numerous MRI studies over the years have shown terrible correlation between structural problems and back pain.11 Time after time, you find that people with pain have no mechanical problems, and people with mechanical problems have no pain.

Cranking up the “holy geez” factor another notch, scientists found in 2006 that a structural problem that everyone previously assumed to always be painful — even I thought so — turns out not to be. Spinal stenosis (narrowing of the spinal canal) has always been regarded as an inevitable cause of stenotic back pain, but the Archives of Physical Medicine & Rehabilitation has pretty much proved that it routinely does not cause pain after all.12

Another good one is a 2009 study structural “instability” isn’t actually the main problem in back pain, because “stabilizing” fractured vertebrae by injecting bone cement doesn’t actually aid the recovery — at all!13

My personal experience in studying this subject for the last several years is that I can hardly look anything up anymore without finding more evidence that structuralism is a generally poor way of explaining people’s pain.

Structure is not completely irrelevant

Of course, biomechanical factors are relevant to some injuries and pain problems. Structuralism is, by the definition I’ve given it, an excessive preoccupation with biomechanical factors.

Biomechanics do matter.

For instance, it is an anatomical fact that women have larger, stronger posterior lumbar joints,14 almost certainly a biomechanical feature that has evolved to cope with fairly major combined stresses of a large, awkwardly off-centre weight and leaning backwards to keep from falling over. This pretty strongly suggests that women without weaker spines, over the aeons, often failed to successfully carry their babies to term because the strain was debilitating.

What are the odds that this evolutionary adaptation makes women immune to the back strain caused by pregnancy? Well … nil! Even today, even with tougher spines, pregnant women suffer increased rates of low back pain.

What we take from this is that the importance of spinal curvature is moderated by evolution. We can clearly see that deviations from normal spinal curvature are a factor in back pain, or women would never have evolved an adaption to cope with it. On the other hand, the same adaptation pretty clearly shows that both men and women are probably adapted enough that spinal curvature alone cannot be a “deal breaker” — if it were, we would have evolved to cope with it.

What are the odds that this evolutionary adaptation makes women immune to the back strain caused by pregnancy? Well, nil …

Another way of putting it: evolution doesn’t care if you have back pain, just as long as you can breed … but it always makes sure that you can do that much. It is easy for nature to saddle us with biomechanical features that are uncomfortable and imperfect, but at the same time we are mostly well-protected from biomechanical features that are routinely crippling.

Thus biomechanical factors are usually much less important than is generally supposed.

But structuralists aren’t all and always wrong. Some biomechanical bogeymen truly are scary, and there are certainly times for a structural diagnosis, and a structural solution. Some problems, like torn menisci in the knee, are obviously more “mechanical” than others — and the menisci in the knee are an awesome example of a high-functioning but vulnerable evolutionary compromise. Medical researchers have had no trouble confirming that, or demonstrating the correctness of the theory by devising therapies and surgeries that fix the problem.

Yet there is no doubt in my mind that the evidence leads us away from getting our knickers in a collective knot over most of the popular structuralist theories.

Biomechanical factors are not completely irrelevant to pain problems, just much less important than is generally supposed.

A degree of structuralism for everyone

There is a flavour of structuralism for every degree of gullibility.

The most outrageous of the chiropractors, the “upper cervical” chiropractors, want us to believe that virtually all problems in the body — both organic disease and musculoskeletal problems — not only originate with the top-most spinal joint, but that they have the skill to reliably correct all of these problems by manipulating only the topmost cervical joint.15 This is far too much for most people to swallow! Yet there is clearly a market for the service — many patients are charmed by such an elegant-seeming explanation for everything that’s ever gone wrong with them.

A patient who is less of a sucker is still likely to fall hook, line, and sinker for exactly the same kind of thinking when they encounter it in a massage therapists office. A short leg diagnosis certainly sounds like a plausible explanation to a lot of people — especially because it usually isn’t presented with any of the cure-all arrogance of the upper cervical chiropractor. Even so, a few more cynical patients will dismiss it. More than a few times people have come to me rolling their eyes about the short leg diagnosis, usually because they simply failed to get any benefit from the therapy, and they felt cheated.

But even a hardened skeptic will often happily swallow a dubious structural diagnosis when it comes from a doctor reviewing an MRI report — in fact, they will swallow it because it comes from a doctor reviewing an MRI report! Unfortunately, the source doesn’t make it any more true than the dippy theories of the craziest chiropractors.

For instance, your sports medicine specialist is often just as wrong as any other structuralist, and nothing has done more to perpetuate this problem than magnetic resonance imaging: a space age technology that is incredibly persuasive, yet can easily be misinterpreted. Science itself has shown countless times that MRI results can and routinely are misunderstood by doctors — in particular, MRIs often reveal harmless structural features and abnormalities that get blown way out of proportion. Gosh, that high-tech medicine sure is persuasive!

Even a hardened skeptic will often happily swallow a dubious structural diagnosis if it comes from a doctor reviewing an MRI report!

Structuralism is immune to credentials. Everyone’s got the disease of structuralism, both alternative health professionals as well as defenders of the mainstream alike.

It’s time for some examples …

Structuralists everywhere

It’s important to understand that there is not really any particular reason for us to believe that we will easily find good advice about aches, pains and injuries. Unfortunately, most patients seeking care for a knee problem or a shoulder problem don’t realize at first that it may be surprisingly difficult to get good help. If their problem proves to be a stubborn one, it may take them several months or even years before they become more cynical and savvy. Along the way, they invariably encounter a lot of structuralism, which they slowly but surely become more and more suspicious of — yet they will lack the expertise to challenge it.

Last week I started working with a new back pain client who had seen at least two dozen structuralists over a period of five years. Literally every health care professional he saw was a dyed-in-the-wool structuralist, and his mind was positively polluted with their theories: he could hardly open his mouth without saying something about his biomechanical problems. Predictably, there was no agreement between the various diagnoses — everyone had diagnosed a different biomechanical bogeyman. What a mess! So I was thrilled to hear that he had just started seeing a new doctor who was — like me — telling him to stop worrying about biomechanics.

But it took this patient five years of searching to find just two non-structuralists! We were the first he’d encountered!

General practitioners have a proven track record of incompetence in these matters16 — they really know nothing, and so they fall into structuralism easily and routinely, simply because they’ve never really thought about it one way or the other. And orthopaedic surgeons are usually (correctly) preoccupied with surgery and so their expertise is naturally slanted towards structuralism.

Chiropractors are structuralists pretty much by definition — the profession more or less exists to scratch that itch, to pander to our desire for a nice, simplistic, structural explanation for our problems. The generally severe problems with that profession are explained in my detailed article, Does Chiropractic Work?

Physiotherapists are notorious for getting preoccupied with the mechanics of the body. In a sense, I believe that they have fallen into this trap for lack of a clear, consistent method of working with patients. Massage therapists massage, chiropractors crack, surgeons operate. What do physiotherapists do? They cherry-pick from a wide variety of therapies, such as strengthening exercises or ultrasound treatments. This is both an obvious strength and a weakness. I have often had the impression that physiotherapists quite literally focus on structuralism because it gives them something to do — something to diagnose, something to therapize.

Physiotherapists may focus on structuralism because it gives them something to diagnose, something to therapize.

Massage therapists are simply not well-trained enough in most jurisdictions. They fall into structuralism because it is the easiest way for them to feel more competent. Diagnosing postural dysfunction is a really cheap and easy way to sound like you’re actually offering a therapy. The sad truth is that most massage therapists, although they may offer all kinds of essentially accidental and general benefits (see Does Massage Therapy Work?), simply do not have the knowledge required to be explaining complex musculoskeletal problems.

Sports medicine specialists are the most likely place to get competent help for aches, pains and injuries. They are the best-trained, the most likely to be reading their journals. However, their practices are usually dominated by major traumatic injuries — knees that are “blown” in football games, that sort of thing. They provide wonderful service to these patients, I believe. But just like your family doctor is out of his depth when you develop vague symptoms, sports medicine specialists often don’t have much to offer patients who aren’t concretely injured. Chronic overuse injuries that just won’t go away, back pain that comes and goes mysteriously, severe neck cricks … these are common problems, yet they are also considered “problem cases” at most sports medicine clinics. I often see patients with these problems who have been to see two or three sports medicine specialists, all of whom were basically stumped: they tossed out a few structuralist explanations — “Well, it’s probably got something to do with your core strength. Let’s get you to the gym…” — and then they seemed to lose interest.

Chronic musculoskeletal pain problems are also considered “problem cases” at most sports medicine clinics.

Who does that leave? What kind of professional is likely to look for explanations more complex and less satisying that the easy but incorrect answers of structuralism?

The answer is: no kind of professional. There simply is no such critter. You simply have to find an individual professional who cares, someone who is a determined, humble and open-minded troubleshooter, someone isn’t obsessed with structuralism. It’s a tall order!

Ooh, dots!

One particularly absurd kind of structuralism involves elaborate “dot connecting” theories. Most structuralism takes the form of straightforward causes like “a narrowed spinal canal causes back pain” — although it doesn’t. Structuralism tends to be presented this way even when the biomechanics are obviously not that simple.

But the real devotees of structuralism like to “connect the dots,” which really tends to impress patients. For instance, a podiatrist might tell you that your fallen arches cause greater strain in your knees, which in turn force you to use your hips differently, which leads to hip weakness, then muscle imbalance in the core, which finally results in back pain. The best dot connectors can be quite convincing, painting elaborate pictures of interconnectedness and inviting you to share a chuckle about how “everything really is connected.”

And the foot bone really is connected to the leg bone, and so on. That these kinds of more complex biomechanical relationships exist is not in question — they do. The trouble is that they are hopelessly complex, effectively impossible to interpret reliably, extremely difficult to treat … and, above all, simply not all that important.

Recall that we have already demonstrated that even simple biomechanical relationships do not correlate well with pain. A narrow spinal canal does not predict stenotic back pain. Many people with ITB syndrome do not have a tight ITB. And so on. Even the most direct relationships tend to defy common sense. The relationships exist, yes, but it turns out that they are fiendishly hard to understand.

Every time you add another link in the chain between a symptom and its proposed cause, you increase the complexity and the chance of error exponentially. Considering that therapists often cannot even agree on a single biomechanical factor, what are the odds that they are going to agree on four inter-related ones?

Therapists use dot-connecting structuralism to impress their patients … and themselves. The dot-connecting thing is usually inextricably connected with an ego trip. This is explored more thoroughly in the article The Humble Therapist.

Why we love to love structuralism: an explanation in search of a phenomenon

Why are patients so tolerant of structuralism? Why do they so consistently believe something that is so easy to disprove? Something that doesn’t even produce results?

Because it is human nature to believe whatever feels good.

Given the choice to believe in something that feels good but is wrong, and something that is true but is not comforting to believe, the human animal will go with whatever “feels good” almost every time. This tends to result in the proliferation of every imaginable kind of product, service and scam that appeals to our desires. We actually do constantly spend time and energy on “solutions” that don’t work — whether it’s a kitchen widget, a stock tip, or physical therapy. Knowing what we all know about human nature, it would be amazing if we weren’t collectively prone to excessive optimism about health care theories.

Carl Sagan’s book, The Demon-Haunted World, thoroughly and brilliantly illuminates this principle of human nature, giving countless examples of how belief and gullibility is driven by our craving to live in our comfort zone. For more about that book, see Review of The Demon-Haunted World: Science As a Candle in the Dark, a book by Carl Sagan.

And, when you really believe that something “makes sense,” you will probably spend a long time looking evidence that you are correct, even when you can’t find any. Your comeuppance will be delayed for years, or even your entire life, by a strong tendency to misinterpret the evidence in your favour. It is typically only young upstarts who can look at the situation and say, “Folks, that emperor is nekkid.”

Yes, I am that young guy, and I’m just cocky enough to say so. But also old enough to have read hundreds of musculoskeletal research papers, and perhaps tens of thousands of abstracts. I can confidently say that there is a clear theme in all that science: there’s nothing there to support structuralism as a general concept, and it’s particularly obsolete in certain niches (low back pain!).

After decades of trying, researchers still can’t find the phenomena that they obviously think “must” exist for structural explanations of pain to work. And, meanwhile, clinicians keep repeating the explanations!

Both patients and professionals are suckers for structuralism for two reasons:

  1. We love the superficial simplicity of it. It’s just satisfying. Although biology should have cured us of this by now, we still tend to think of our bodies as unusually complicated machines, instead of an absurdly complex and on-going evolutionary experiment in chemistry.
  2. Structuralist theories aren’t necessarily simple in their details, and may even involve elaborate dot-connecting, but they all basically boil down to something that we can tell people next day at the water coolor: “My pelvis is out of whack.” So easy! And so much the better if we can impress upon our audience that your clever therapist was able to trace the causal pathway through nine intermediate misalignments — but it’s still a simple explanation, in essence.

But the body is assuredly not just a complicated machine. Mechanical imagery is almost completely useless in musculoskeletal health care. By analogy, doctors have learned that there is a great deal more to an obstructed artery than “clogging” — instead, it involves a bewildering array of chemistry mediated by countless factors, a mess the likes of which no one dreamed possible a hundred years ago.

Similarly, therapists must get past mechanics. Joints may be like hinges in a superficial way, but they are not hinges, work nothing like hinges, and fail nothing like hinges. Yet structuralism is a rather transparent and pathetic attempt to explain pain as a failure of a machine, described in terms that are quite simplistic compared to the breathtakingly complex reality that is your tissues.


Appendix: “I have been humble for 2 decades now” — a classic case of structuralism and therapeutic arrogance

I received a note from a reader — allegedly a colleague and kindred spirit. He briefly expressed his appreciation for my writing, and then asked:

Would you like to know what actually causes trigger points? I have been at this for twenty years and have the answers that we all search for.

Uh oh.

Clearly, this is someone who fancies himself a “healer” with special knowledge — almost certainly a structuralist theory. His delusions of grandeur are betrayed not only by his belief that he has “the answers that we all search for,” but by his teasing lack of detail. If he really has special knowledge, why would he ask me if I want to know? Why wouldn’t I? Why be guarded or vague? Just share! Can you imagine a scientist writing to another scientist and saying, “Would you like to know how things really work?”

I decided to bite, just to see what he would say, and his reply was vain and vague, with hand-waving references to an “amazing” therapeutic protocol that can work marvels with pain patients, and all of it depending on something — he doesn’t say what — in the feet. This is classic wind up for a doozy of a structural theory to explain all pain. For structuralists, “it all” always hinges on one critical biomechanical factor.

Can you imagine a scientist writing to another scientist and saying, “Would you like to know how things really work?”

I pointed out that his lack of humility, lack of detail, and lack of scientific evidence was all fairly off-putting. And this was his reply, pitch perfect for a delusional “healer.” I have reproduced it here word for word, because it is just such a gloriously irritating example of this kind of thinking, which is absolutely rampant in alternative health care:

I appreciate what you are saying, I have been humble for 2 decades now, in fact this has been my ministry for 20 years. As I have said I don’t have all the answers and I don’t have a panacea for anything, neither have I cured anything, I’ve worked with many alternative types of medicine and have used these methods to end my own bout with cancer. What makes my method work is a complimentary adjustment top to bottom.  What makes the adjustment stay is the cuboid [a small foot bone] being held in place.  If you have the skills needed to reduce or eliminate the scoliosis then you can appreciate that just to get proper treatments in some areas, you have to fight. I am entirely guilty of being an old warrior, who finally has won. I don’t need to argue any more, I demonstrate. I have no desire to change the way things are, only to save as many as I can. Technical explanations are good for conversing with doctors, but my mission is to communicate with the average joe who has been through the “mill” and has lost hope, these are my flock. To check out my “ extraordinary claims” You will find confirmation in Dr. Warren Hammers book entitled; Soft tissue examination and treatment by manual methods pg 425.

There are so many things about his thought process that are disturbing that I hardly know where to begin, but here are the highlights:

That brings oversimplification of a complex subject to new lows!

And a final dig I can’t resist…

This is why so many doctors so reasonably object to alternative medicine: because it is, so often, so disappointingly ego-driven.

“I have been humble for 2 decades now” is not an expression of humility.

Further Reading

If you found this article useful, you may also be interested in some other articles I’ve published:

Notes

  1. Just in case anyone needs to know exactly how ridiculous that is: the coriolis effect is a macroscopic effect, and does not have a visible effect on small systems like water going down a drain. “The Coriolis force is so small that it plays more no role in determining the direction of rotation of a draining sink anymore than it does the direction of a spinning CD” (from the “Bad Coriolis” page). The idea that coriolis force would be relevant to musculoskeletal health is about as air-headed as you can get. Return to text.
  2. I do not think that this is an unreasonable accusation. Patients with great anxiety, pain and frustration are especially vulnerable to persuasion, or “therapy by charisma.” This is why I really make an effort in my work to be reassuring without offering miracles, to be knowledgeable without claiming to “know” what the problem is. All too often, patients in pain will cling to whatever ideas you throw at them… so you have to be careful what you throw at them! Structuralists rarely seem to show such restraint, and consequently patients emerge from therapy with structuralists feeling much too sure of their diagnosis. There is no zealot like a convert! In this context, clinicians are more like clergy than health care professionals. Return to text.
  3. Dye. Clinical Orthopaedics & Related Research. 2005. From the article: “The fundamental issue at the core of the patellofemoral pain problem, in this author’s view, has been the limited conceptualization of the genesis of anterior knee pain to that of a pure structural and biomechanical perspective. Such an intellectually constrained view does not include the complex pathophysiologic factors that may be of etiologic significance in living, symptomatic joints.” Return to text.
  4. Deyo et al. New England Journal of Medicine. 2001. Return to text.
  5. Bogduk. Medical Journal of Australia. 2000. Return to text.
  6. For an overview of his work, see Review of John Sarno’s Books about Low Back Pain. Return to text.
  7. Grundy et al. Lancet. 1984. From the abstract: “In a case-control study, in which a specially designed questionnaire and a ‘locating jig’ were used to investigate the association between difference in lower limb length and other disproportion at or around the sacroiliac joints and the existence of chronic low back pain, no association was found. Chronic back pain is thus unlikely to be part of the short-leg syndrome.” Return to text.
  8. Grob et al. European spine journal. 2007. Return to text.
  9. Devan et al. Journal of Athletic Training. 2004. Return to text.
  10. Moseley et al. New England Journal of Medicine. 2002. Return to text.
  11. See Boden, Jensen, Weishaupt, Stadnik, and Borenstein. Return to text.
  12. Haig et al. Archives of Physical Medicine & Rehabilitation. 2006. In this study, about 150 people were assessed for back pain in different ways, including MRI, but “radiologic and clinical impression had no relation.” In other words, there was no useful similarity between evaluation of the patient with MRI, and evaluation by examination and taking a history. “The impression obtained from an MRI scan does not determine whether lumbar stenosis is a cause of pain.” Since MRI does in fact identify narrowing of the spinal canal, and this is the whole basis of diagnosing spinal stenosis with MRI, these results also strongly imply that a narrowed spinal canal does not (alone) cause back pain. Return to text.
  13. Buchbinder et al. New England Journal of Medicine. 2009. This study presents strong evidence that there is “no beneficial effect” to stabilizing fractured spines with injections of bone cement (vertebroplasty), a common and apparently dubious procedure. The frequency of this “surgery” — though it is usually performed by surgeons, it’s just an injection — will now drop off dramatically, as surgeons demonstrate that they respect the evidence (when good science shows that something doesn’t work, doctors stop doing it).

    The evidence is also a poetic addition to the evidence that spinal fragility is not the cause of back pain. If stabilizing the spine with cement doesn’t resolve symptoms, it strongly suggests that instability wasn’t the problem to begin with.

    Strictly speaking, the only thing this evidence can tell us is what it told us: patients with osteoporotic fractures who got vertebroplasty recovered no better than those who only thought they got vertebroplasty. But the rationale for vertebroplasty has always been cave-man simple: Ooog. Vertebrae busted. Hurt. Thag make stronger. Inject glue. Ugh. Supposedly these fractures are painful because the spine is unstable — hardly an unreasonable assumption — and therefore stabilizing them will help. Except it didn’t! Not in these patients.

    So maybe it’s not the instability that’s causing all the pain.

    For a much more detailed analysis of this, see Dr. David Gorski’s excellent article on the subject. Return to text.
  14. Whitcome et al. Nature. 2007. Return to text.
  15. A Chiropractic Tomorrow? Gregory. 2007. On this webpage, prominently available as the primary source of information about a upper cervical chiropractic therapy, a list of incredible claims are made: “A child with bronchial asthma breathes normally again, the acute attack stilled by a chiropractic adjustment. A man suffering intense pain from sciatica returns to his daily labors after weeks of suffering, relieved by a chiropractic adjustment. A lady patient, tormented for years by migraine, is freed from pain by the chiropractic adjustment. A boy who constantly suffered from ‘stomach pains’ lives a normal pain-free life after a chiropractic adjustment. A girl with a twisted pelvic girdle is liberated from her braces as a result of a chiropractic adjustment. The patient who could not raise his arm, could not sleep except under sedation because of the pain, completely recovers after his chiropractic adjustment.” The author grandly concludes “[Upper cervical chiropractic] has succeeded in the care of the sick in case after case when other healing arts have failed” yet freely (to his credit) admits that the profession “must provide a rationale, a scientific explanation of the fundamental reasons for its existence.” Yes, they must! And they have not, after decades of trying. Again, see Does Chiropractic Work? for more detail about this. Return to text.

  16. Most doctors are well aware that there are serious shortcomings in the medical management of most musculoskeletal problems, especially chronic pain cases. Dr. Jonathon Tomlinson, an instructor at St. Leonards Hospital in Hoxton, explains that “undergraduate training is focused on hospital orthopedics (broken bones and anything else that’s amenable to surgery) or rheumatology (nasty inflammatory diseases) which comprise a minority of the aches/pains/strains and injuries that people actually suffer from.”

    Medical researchers have done many studies showing that most doctors do not understand aches and pains or heed expert recommendations. A good recent example is a paper in the Archives of Internal Medicine showing that family doctors frequently ignore guidelines for the care of low back pain — see Williams et al.

    More generally, the Journal of Bone and Joint Surgery, and the Journal of the American Osteopathic Association, have both published papers recently showing that physicians simply do not have an adequate understanding of musculoskeletal medicine. In 2002, Freedman et al felt that “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.” Then again in 2005 in JBJS, Matzkin et al concluded that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” Most recently, in 2006, Stockard et al wrote “82% of allopathic graduates ... failed to demonstrate basic competency in musculoskeletal medicine.”

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  17. Whenever I make this criticism, I open myself up to a charge of hypocrisy, because there are scattered errors on my website, probably even on this very page. But it’s a matter of degree. I would only criticize someone elses communication skills when the problem is pretty serious, and relevant to the issue: when the errors are thick and nasty, and furthermore the sort of errors that betray ignorance of the subject matter, like a chiropractor who writes “veterbra” three times in the same document. (Yes, I have seen this.) Once I would forgive as a typo. But three times? Three times makes me wonder. Not everyone’s a writer, but such errors are more serious that simple lacking a knack for writing — they expose a lack of mental rigour. Return to text.